P 1.

Electrolytes
< Na+, K+, Ca++
P 2. IV therapy
< Indications, types, needles, etc
P 3. Types of IV solutions
< Hypertonic, hypotonic, isotonic (indications for
each)
P 4. Math calculations
P 5. Crystaloid versus Colloid
P 6. Complications of IV’s
 Intravenous Fluids
Overview
P IV fluids and medications, and total
parenteral nutrition will be considered.
P IV therapy and safe administration of IV
meds is very critical because absorption in
pharmacokinetics is eliminated.
P What the nurse puts into the vein is
immediately distributed, there is no taking
back a mistake.
P It is critical for the nurse to be very familiar
with all drugs and electrolyte solutions
administered IV.
Net movement of fluids within
compartments
 Fluid shifts in disease

P Fluid loss:
< GI: diarrhoea, vomiting, etc.
< renal: diuresis
< vascular: haemorrhage
< skin: burns
P Fluid gain:
< Iatrogenic:
< Heart / liver / kidney failure:
Renal regulation of sodium and
potassium balance
 Sodium (Na+) Discussion
Background

P Most abundant cation (90% of the electrolyte

fluid) and the chief base of the blood.
P Primary functions are to chemically maintain
osmotic pressure, acid base balance and to
transmit nerve impulses.
P Normal level is 135 -145 mEq/L
 Sodium (Na+) 000000000
Hyponatremia (a decreased level) reflects a relative excess
of body water, rather than a low total sodium level.

P Causes include: Severe burns, CHF , Edema

(dilutional) , NG suction
P Excessive fluid loss (severe diarrhea,
vomiting, sweating), drugs such as diuretics
P Excessive IV induction of non electrolyte
fluids (glucose), diabetic acidosis
P Addison’s disease, malabsorption syndrome
P Severe nephritis, pyloric obstruction,
Hypothyroidism
 Sodium (Na+)00000000000000
Hypernatremia (an increased sodium level) is uncommon

P Causes include: Dehydration d/t insufficient

water intake, Primary aldosteronism
P Coma, Cushing’s disease, Diabetes insipidus
P Tracheobronchitis
 Potassium (K+)
Background

P Most abundant principle electrolyte of the

intracellular fluid (90 % found within the cell)
P Principle function relates to electrical activity
of heart, acid base balance, nerve
conduction
P Normal value is 3.5 -5.3 mEq/L
 Potassium (K+)
Hypokalemia (decreased levels) is the shifting of K+ into
cells, K+ loss from GI and biliary tracts, renal K+ excretion,
and reduced K+ intake:
P Causes include: diarrhea, vomiting,
starvation, malabsorption
P Excessive sweating, Draining wounds, burns,

P Respiratory alkalosis, Diuretics, DKA

Potassium (K+)
Slide
 Calcium (CA++)
Background

P Only ionized calcium can be used by the

body in such vital processes as:
P Muscular contraction, cardiac function,
transmission of nerve impulses, and blood
clotting
P Normal values: 8.6 -10.0 mg/dl
 Calcium (Ca++)
Hypocalcemia (decreased total calcium)

P Causes: alkalosis, pancreatitis,

hyperphosphatemia, immobility, removal of
parathyroids during surgery
Calcium (Ca++)
Trousseau’s sign
Calcium (Ca++)
Chvostek’s sign
P IV FLUIDS?
< NaCl, .45NaCl, NS, .9NS
< LR
< D5W, D5W.45NS, D5WLR
< 50cc, 100cc, 250cc, 500cc, 1000cc
 Intravenous therapy
P Peripheral IV therapy is the most common
method of gaining access to the client’s
venous system.
P Used to replace fluids, electrolytes, and
nutrient losses, anti-infectives, blood
products, Dyes
P Orders are necessary for initiation of therapy
= (1) Specific type of solution; (2) Rate of
administration; (3)Volume of infusion; (4)
Time of infusion intended
P Intravenous fluids are usually provided to:
< Provide volume replacement
< Administer medications, including electrolytes
< Monitor cardiac functions
 Indications for an IV
P 1.Establish or maintain a fluid or electrolyte
balance
P 2 Administer continuous or intermittent
medication
P3 Administer bolus medication
P4 Administer fluid to keep vein open (KVO)
P5 Administer blood or blood components
P6 Administer intravenous anesthetics
P7 Maintain or correct a patient's nutritional
state
P 8 Administer diagnostic reagents
P9 Monitor hemodynamic functions
 TYPES OF NEEDLES
P Steel Needles: Eg: Butterfly catheter. They
are named after the wing-like plastic tabs at
the base of the needle.
P They are used to deliver small quantities of
medicines, to deliver fluids via the scalp
veins in infants, and sometimes to draw
blood samples (although not routinely, since
the small diameter may damage blood cells).
These are small gauge needles (i.e. 23
gauge).
P
P Over the Needle Catheters Example:
peripheral IV catheter. This is the kind of
catheter you will primarily be using.
P Catheters (and needles) are sized by their
diameter, which is called the gauge.
P The smaller the diameter, the larger the
gauge.
P Therefore, a 22-gauge catheter is smaller
than a 14-gauge catheter.
P Obviously, the greater the diameter, the
more fluid can be delivered. To deliver large
amounts of fluid, you should select a large
vein and use a 14 or 16-gauge catheter. To
administer medications, an 18 or 20-gauge
catheter in a smaller vein will do.
P For example, a patient comes into the ED
with gastroenteritis and is dehydrated from
vomiting and diarrhea.
P Acutely, she receives a fluid bolus to expand
her intravascular volume. Her blood
chemistry shows that her electrolytes are a
bit off, so the IV fluid is adjusted to bring
them within normal parameters.
P She is also given medication for nausea via
her IV. She will remain on maintenance IV
fluids until she is able to drink adequate
amounts of fluids.
 Types of IV FLUIDS

P Isotonic fluids
P Hypertonic fluids
P Hypotonic fluids
 Types of IV FLUIDS
Isotonic fluids

P Close to the same osmolarity as serum. They

stay inside the intravascular compartment,
thus expanding it.
P Can be helpful in hypotensive or hypovolemic
patients.
P Can be harmful. There is a risk of fluid
overloading, especially in patients with CHF
and hypertension.
P Examples: Lactated Ringer's (LR), NS
(normal saline, or 0.9% saline in water).
P Isotonic fluids contain an approximately
equal number of molecules (blue dots) as
serum so the fluid stays within the
intravascular space.
P Remember that fluid flows from an area of
lower concentration of molecules to an area
of high concentration of molecules (osmosis)
to achieve equilibrium (fluid balance).
P In this example, there is no fluid flow into or
out of the intravascular space.
 Hypotonic fluids
P Have less osmolarity than serum (i.e., it has
less sodium ion concentration than serum). It
dilutes the serum, which decreases serum
osmolarity. Water is then pulled from the
vascular compartment into the interstitial fluid
compartment. Then, as the interstitial fluid is
diluted, its osmolarity decreases which draws
water into the adjacent cells.
P Can be helpful when cells are dehydrated
such as a dialysis patient on diuretic therapy.
May also be used for hyperglycemic
conditions like diabetic ketoacidosis, in which
high serum glucose levels draw fluid out of
the cells and into the vascular and interstitial
compartments.
P Can be dangerous to use because of the
sudden fluid shift from the intravascular
space to the cells. This can cause
cardiovascular collapse and increased
intracranial pressure (ICP) in some patients.
P Example: .45% NaCl, 2.5% dextrose
P Hypotonic fluids contain a lower number of
molecules than serum so the fluid shifts from
the intravascular space to the interstitial
space (represented by the green arrows).
P This decreases the interstitial space
osmolarity (because of the increase of fluid
and constant number of molecules within it)
which then causes fluid to move into the
cells. Note that the green arrows represent
fluid movement, not molecule movement.
 Hypertonic fluids
P Have a higher osmolarity than serum. Pulls
fluid and electrolytes from the intracellular
and interstitial compartments into the
intravascular compartment. Can help
stabilize blood pressure, increase urine
output, and reduce edema.
P Rarely used in the prehospital setting. Care
must be taken with their use. Dangerous in
the setting of cell dehydration.
P Examples: D5W.45% NaCl, D5WLR, D5W
NS, blood products, and albumin
P Hypertonic fluids contain a higher number of
molecules than serum so the fluid shifts from
the interstitial space to the intravascular
space (represented by the green arrows).
P This increases the interstitial space
osmolarity (because of the loss of fluid and
constant number of molecules within it) which
then causes fluid to leak out of the cells.
 There are two main groups of
fluids

P Crystalloid
P Colloid
 Crystalloid
P Are isotonic and remain isotonic and are
therefore, effective volume expanders for a
short period of time.
P However, both the water and the electrolytes
in the solution can freely cross the
semipermeable membranes of the vessel
walls (but not the cell membranes) into the
interstitial space, and will achieve equilibrium
in two to three hours.
P They are ideal for patients who need fluid
replacement.
P When using an isotonic crystalloid for fluid
replacement to support blood pressure from
blood loss
< remember that 3 mL of isotonic crystalloid
solution are needed to replace 1 mL of patient
blood. This is because approximately two thirds of
the infused crystalloid solution will leave the
vascular spaces by about one hour.
 Crystalloid
P Generally, a good rule of thumb is that initial
crystalloid replacement should not exceed
three liters before whole blood is instituted.
P Continued use of crystalloids runs the very
real risk that the fluid that has leaked into the
interstitial space will result in edema,
primarily in the lungs (pulmonary edema).
P Examples: Lactated Ringer's (LR), NS
(normal saline).
 Colloid
P These contain molecules (usually proteins)
that are too large to pass out of the capillary
membranes and therefore remain in the
vascular compartment.
P The large protein molecules give colloid
solutions a very high osmolarity. As a result,
they draw fluid from the interstitial and
intracellular compartments into the vascular
compartment.
P They work well in reducing edema (as in
pulmonary or cerebral edema) while
expanding the vascular compartment.
P Colloids can produce dramatic fluid shifts and
place the patient in considerable danger if
they are not administered in a controlled
settings.
P Examples: albumin and steroids
 The rules of fluid replacement:

P Replace blood with blood

P Replace plasma with colloid
P Resuscitate with colloid
P Replace ECF depletion with saline
P Rehydrate with dextrose
 How much fluid to give ?

P What is your starting point ?

< Euvolaemia ?( normal )
< Hypovolaemia ?( dry )
< Hypervolaemia ? ( wet )
P What are the expected losses ?
P What are the expected gains ?
 What are the expected losses ?

P Measurable:
< urine ( measure hourly if necessary )
< GI ( stool, stoma, drains, tubes )
P
P Insensible:
< sweat
< exhaled
 What are the potential gains ?

P Oral intake:
< fluids
< nutritional supplements
< bowel preparations
P IV intake:
< colloids & crystalloids
< feeds
< drugs
 Veins of the Hand

P 1. Digital Dorsal veins

P 2. Dorsal Metacarpal veins
P 3. Dorsal venous network
P 4. Cephalic vein
P 5. Basilic vein
 Veins of the Forearm

P 1. Cephalic vein
P 2. Median Cubital vein
P 3. Accessory Cephalic vein
P 4. Basilic vein
P 5. Cephalic vein
P 6. Median antebrachial vein
 Flow Rates

P Microdrip sets Allow 60 drops (gtts) / mL

through a small needle into the drip chamber
P Macrodrip sets Allow 10 to 15 drops / mL
into the drip chamber
P Fluid may be ordered at a KVO or TKO rate.
This means to Keep the Vein Open, or run in
fluids very slowly, enough to keep the vein
open, but not really deliver much volume.
P At times, you may desire a faster flow rate.
This is usually expressed in mLs / hour. In
other words, how much fluid do you want
your patient to receive each hour? A
common "maintenance" amount, for
instance, would be "run it in at 125 an hour".
Your patient would receive 125 mL of fluid
every hour.
P Unless you are using an electronic pump to
deliver the fluid at precise amounts, you will
need to learn how to set a flow rate yourself.
This is usually done by counting the number
of drops that fall into the clear drip chamber
on the IV administration set in one minute.
To do this, you must know what size
administration set you are using (micro or
macrodrip). Plug the numbers into the
following formula and you've got it!

P (volume in mL) x (drip set) gtts

P ------------------------------------ = ------
P (time in minutes) min
Intravenous Fluids
 Maintenance IV Fluids
P Who Needs Them?
P What’s Maintenance?
P How Much H20?
< 100 cc/kg/d 1st 10 Kg
< 50 cc/kg/d 2nd 10 Kg
< 20 cc/kg/d for every Kg > 20 Kg
P Na?
P K?
P Dextrose?
P
 Maintenance IV Fluids

P 70 Kg person
< 1000cc + 500cc + 1000cc = 2500cc=105cc/hr
< Na 140-280 meq/d = 200 meq/2.5L = 80meq/L
< 1/2NS =77 meq/L
< KCl 70 meq/d = 70 meq/2.5L = 28meq/L
< + 20 meq KCl/L
< D5 1/2NS + 20 meq KCL/L @ 105 cc/hr
 Calculation

P Order reads 1000ml of 5 percent dextrose in

water (D5W) at 125 ml/ h. You have
available 20 drop factor tubing. Calculate the
drops per minute.
< ML/hrX DF 125X20
– --------------- = gtt/min ----------------- = 42 gtt/min
– 60
– Minutes
P Order reads 3000ml of a multiple electroyte
fluid over 24 hours. You have available 20
drop factor tubing. Calculate the drop per
minute.
P Formula:
P ml/h X DF 125 X 20
– ---------------- = --------------- = 42 gtt/min
– Minutes 60
P
 Complicated IV calculations

P Order to read: Order: Nipride 1 g IV in 250

mL D5w at 4 mcg/kg/min for a patient
weighing 250. Administer at _____ mL/hr?
P http://home.sc.rr.com/nurdosagecal/
P http://www.accd.edu/sac/nursing/math/defaul
t.html
 Complications Of IVs
Bruising

P Bruising - may occur at any time during an

episode of intravenous therapy
 Cellulitis

P Infection - adhering to aseptic technique is

vital in the prevention of intravenous related
infections. Asepsis should be maintained at
insertion, during clinical use and at removal
of the device.
 Infiltrate
P Infiltration - the inadvertent administration of
non-vesicant solution/medication into
surrounding tissues.
P Although the solution is non-vesicant, tissue
damage may still occur.
P Regular monitoring of infusion sites, choice
of correct access device/intravenous
dressing and the use of in-line pressure
monitors may help to reduce the extent to
which infiltration occurs
P Discontinue the IV, place cold compress on
to decrease swelling then warm compress to
move fluid out of the interstitial spaces
 Extravasation

P Extravasation - the inadvertent administration

of a vesicant substance into the tissues can
have disastrous outcome.
 Phlebitis

P Infusion Phlebitis - inflammation of the vein

associated with infusion phlebitis is seen in
this photograph. Careful/regular monitoring
of intravenous access sites is recommended.
 Systemic Complications

P Systemic complications include sepsis,

pulmonary thromboembolism, air embolism,
and catheter-fragment embolism.
 Parental nutrition (TPN)
(Hyperalimentation)
P Parental nutrition is the administration
through a central or other intravenous line of
essential proteins, amino acids,
carbohydrates, vitamins, minerals, trace
elements, lipids, and fluid.
P Used to improve or stabilize the nutritional
status of cachectic or debilitated patients who
cannot take or absorb oral nutrition to
maintain their nutritional status.
P Adverse effects many include mechanical
problems (IV lines), infections, metabolic
imbalances, gallstone development, nausea
 TPN
P TPN solutions are hyperosmotic (three to six
times the osmolarity of normal blood)
P Fluid shifts can stimulate fluid shifts between
body fluid compartments.
P Hyperglycemia (hyponatremia and
hypokalemia) can cause osmotic diruresis =
dehydration
P If client has an accompanying cardiac or
renal dysfunction = over hydration, CHF,
pulmonary edema